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HIE Sustainability Secrets

October 25, 2011
by Jennifer Prestigiacomo
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NeHC Report Shares HIE Success Stories of Alternate Revenue Streams and Payer Buy-In


Getting effective stakeholder engagement, including that of payers, and creating innovative value-added services that provide alternate revenue streams beyond basic subscription services, are just a couple of the common traits of the flourishing health information exchanges profiled in the sustainability report released in August by the National eHealth Collaborative.

How can health information exchanges (HIEs) ensure that they will have the financial viability to be around for the long haul? A recent report by the Washington, D.C.-based National eHealth Collaborative (NeHC) can provide some guidance.

The report, “Secrets of HIE Success Revealed: Lessons from the Leaders,” provides case studies on 12 successful, sustainable HIEs nationwide. The HIEs represent a diverse group of organizations, including for-profit entities, non-profit entities, and a government agency. NeHC CEO Kate Berry said in a Healthcare Informatics podcast (/article/podcast-sustainability-tips-hies) in August that the organizations were chosen based on their innovative strategies and business models, the value and impact they are having in their respective communities, their maturity in achieving sustainability and the geographic diversity among them.


Of all the HIEs profiled in the NeHC report, one of the commonalities they share is effective stakeholder engagement. Rochester RHIO, which is based in Rochester, N.Y. and serves 13 counties, illustrates this concept well, as it was founded in 2006 not only with a $4.4 million state grant, but $1.9 million in funding from local businesses, hospitals, and payers. Its user mix is as diverse as its board, and includes hospitals, physician practices, home care, long-term care, and behavioral health settings. “The major theme in our implementation was that we realized one of the values is to have as much information as possible; the other is to have as many people using it as possible,” says Marty Lustick, M.D., Rochester RHIO board member, and senior vice president and corporate medical director at Excellus BlueCross BlueShield. “You need both of those at the same time in order for people to gain confidence that there's value in it.”

Kate Berry
Kate Berry

Jill Eisenstein, Rochester RHIO's associate director, adds that to get these other healthcare entities involved in the RHIO, the barriers for adoption have to be very low. To that end, Rochester RHIO provides a virtual health record portal that only requires the healthcare organization to have Internet, rather than a full EHR, to access patient information.

Dev Culver
Dev Culver

Enlisting business leader support early on, says Lustick, is extremely important for the viability of any exchange. He notes that Rochester RHIO received both financial support and personal involvement in the board from business leadership. “Inevitably in this process when you're doing something this big and this new, there are times when there is ambivalence from the point of view of any particular healthcare stakeholder about how this is going to improve its position competitively,” he says. “The business leaders play a major role in keeping everybody focused on the community as a whole.”

Berry says being a trusted entity is a prime goal among HIEs, and hard work has to be done to build trust among stakeholders and maintain a reputation as a reliable, neutral entity that values protecting patient information and the interests of its participants above all else. Jacksonville Fla.-based Availity, which is a commercial for-profit that serves nearly 20 states with its multi-payer web portal that provides physicians with real-time access to patient information such as eligibility, benefits, and claim status, is the only profiled exchange of its kind that was borne from payers. It owes its vaunted status to starting with a small set of transactions and focusing on core strengths. In 2001 two health plans, Blue Cross and Blue Shield of Florida and Humana, agreed on guiding principles to gain value in finding billing efficiencies in providers' offices, while giving customers a common look, feel, and user experience.

Availity also exemplifies another core trait of a successful HIE, which is moving beyond sheer information exchange to operating on strong business directives and value-add services. “One of biggest challenges has always been, how do you create a sustainable model that will live beyond the grant money,” says Russ Thomas, COO and president, Availity. “We on the other hand went at it from solving today's problems in the physician office, which was inefficiencies in the way with which they interacted with health plans.” Thomas says that Availity has been profitable since 2004, and he owes that in large part to only exploring opportunities that have a business model behind them.

“We believe we're in a good position to leverage the existing network we have, which is 200,000-plus physicians and more than a billion transactions over our network, to be a part of that next generation of health information,” Thomas says.


Three of the HIEs profiled in the NeHC report, Quality Health Network (Grand Junction, Colo.), Availity, and Rochester RHIO, drew much of their success from incorporating the payer community as a key stakeholder, leader, and revenue source from the beginning. These HIEs convinced payers of the benefits of the HIE's services in terms of cost savings achieved through reductions in services utilization, NeHC's CEO Kate Berry notes.

“Employers and health plans as purchasers of healthcare do see the value of health information exchange, and how that is going to lead to better quality and care coordination and more effective cost management because they are going to avoid duplicated tests and better manage the care so you have lower downstream costs,” Berry says.

Rochester RHIO had a unique start in that its original CEO, Lustick's predecessor, was from Exellus Bluecross Blueshield and saw HIE as a positive benefit to the community, and thus, played a leadership role from the beginning.

“In Rochester one of the things the RHIO has done is develop a really sophisticated system of metrics to enable them to both do their own quality improvement projects and demonstrate the value in the community in a very quantitative way,” Berry says. “But they also have that metric system in place so they can support specific quality improvement projects that the purchasers want them to do.”

Getting payer support isn't always easy. Ideally, HealthInfoNet (HIN), Maine's statewide HIE based in Portland, would like to get one-third of its total fees to come from payers, but there has been a lack of interest until recently. Executive Director Dev Culver says that his organization plans to get MaineCare, the state's Medicaid program, interested in the HIE by addressing a key issue in the state, high utilization of the emergency room (ER) for non-emergent reasons. HIN would develop a notification system to alert care managers to ER visits for one of 14 different diagnoses. The care managers would then provide the patient with education and recommend appropriate follow-up to avoid future ER visits.


Lately, Culver says that conversations with other insurers have been promising. With accountable care organization (ACO) legislation looming, which could possibly create some competition, payers are looking for alternate ways to bring value to their customers. An idea for HIN to appeal to payers would be to offer them population analytics, showing their members in the context of predicted cost and outcome, all with the benefit of clinical data.


Many of today's experienced HIEs are evolving their services beyond just clinical information exchange and creating value-added services to benefit stakeholders and build new revenue streams for the HIE. These new financial opportunities include many revenue generators, including analytics, ACO support services, and patient portals.

Rochester and HIN are both planning patient portals. Rochester's portal allows patients to submit informed consents online, upload advance directives like living wills, and request an audit of access to their EHR. Next steps include creating a PHR gateway that establishes two-way connectivity to the HIE from the patient's untethered personal health record (PHR), like Microsoft's HealthVault.

Culver says that HIN is finishing due diligence on its robust patient portal to be completed early next year. The same product is currently being used by McGill University Health Centre in Montreal. The portal will have significant functionality not only to allow patients access to their health information in easy-to-understand language, but also to permit them to self-document, which will then be coded into medical taxonomy so it can be used for interpretation purposes. “Then there's a really interesting and significant introduction of social media within the PHR and the opportunity that it creates for building groups [of patients] by like condition or introducing product lines that support these types of conditions,” he says. “[For example], there's a huge market that tries to support those people who are actually caregivers for Alzheimer's patients.”

HIN, a nonprofit, is also pondering the creation of a for-profit subsidiary for particular ventures like licensing intellectual property. In working with its patient portal partner, HIN will be used as a test case for regional extension centers (RECs) and HIEs nationwide, and what HIN adds in intellectual property, it will be able to profit from. “So anytime we can do something that is saleable outside the borders of Maine,” says Culver, “we will need a vehicle to help manage that process that is not in our direct mission as an exchange.”

Another revenue stream that HIN is building is a statewide medical images repository to house its average of 1.8 million studies a year. The exchange is in the process of reviewing the seven vendors that have responded to its request for proposal. HIN will set a per-study fee, which will benefit healthcare organizations, Culver says, by driving cost down because of the benefit of volume. Culver adds that there will be other direct economic benefits including organizations having access to Digital Imaging and Communications in Medicine (DICOM) standardization in a vendor-neutral architecture, which will aid access and give organizations a more holistic patient view.

Down the east coast in Florida, Availity is in the process of coming up with a suite of services to serve up relevant clinical information when providers check eligibility. In the short-term, Availity is focusing on creating tools for today's demands that include the 5010 transaction standard and the ICD-10 migration. Later down the line, Availity will develop tools like an identity management service that identifies the patient and provider properly throughout the care process, as well as other tools like single sign-on, secure messaging, and mobile device access.

“Availity is in the information business,” Lustick says. “So for us it's how do we serve up our information in a seamless, user-friendly way through private independent applications, through our portal, through our practice management and EHR vendor partners-wherever and however the physician works. We have to be able to meet their information needs.”

Healthcare Informatics 2011 November;28(11):24-28

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